Dr Nicki Mazey

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Obesity Primary Care Management

• Dr Nicki Mazey

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Introduction

• Predisposing factors
• Co-morbidities
• Managing Obesity in primary care
• Sleep apnoea/Binge eating
• Tools available
• Anti-obesity medication
• Bariatric Surgery (NICE)
• Health and Safetyyawn.

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Causes of Obesity

• Cushings (rare)
• Hypothyroidism
• Medication (antipsychotics, insulin, beta
  blockers, steroids.)
• PCOS
• Immobility
• Binge eating/psychological disorders
• Genetic disorders. Prada Willi syndrome.
• Depression.

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Co-morbidities

• CVS (MI/BP/IHD)
• Respiratory (sleep)
• Malignancy
• Diabetes
• Dyslipidaemia
• Musculoskeletal
• Depression/Low self esteem/ED
• GIT

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Managing Obesity in primary care

• Engage
• Screen
• Referral
• Monitoring
• Education
• Patients dont lie
• Smoking

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History

• Onset. Factors causing and maintaining
• Eating Patterns
• Weight loss attempts
• Activity. Limiting factors
• FH
• Co-morbidities (sleep and intertrigo)
• Meds
• Alcohol
• Smoking
• Occupation

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Examination

• General
• Height Weight BMI Fat mass BP Pulse
• Cushingoid
• Thyroid
• Hair/secondary sexual characteristics
• CVS
• Resp
• Skin infections

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Investigations

• Bloods
• Dexamethasone suppression
• Depression screening HAD scores
• Sleep apnoea

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Sleep Apnoea Epworth Scores
How likely are you to doze off or fall asleep in
the following situations, in contrast to feeling
just tired? This refers to your usual way of life
in recent times. Even if you have not done some
of these things recently try to work out how they
would have affected you Use the following scale
to choose the most appropriate number for each
situation
0 no chance of dozing 1 slight chance of
dozing 2 moderate chance of dozing 3 high
chance of dozing
The score obtained by adding the numbers leads to
a total 0 - 9 - average score, normal
population 10 - 24 - sleep specialist advice
recommended
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Binge Eating

• History top tips!
• Initial management
• distraction, regular meals, fluoxetine
• Therapy referral

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Tools available

• Support
• Address depression
• Exercise referral
• Dietician referral
• Psychotherapy
• Eating disorders
• Physiotherapy
• Reduce obesity prone medication where possible
  (Atenolol/steroids/insulin)
• Anti-obesity medication
• Very low calorie diets
• Commercial organisations
• Pedometers
• Local exercise/council/university organised
  exercise
• Bariatric surgery list of nice guideline
  criteria for surgery

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Anti-obesity medication

• Orlistat, Sibutramine, Rimonabant, Amphetamines
  and dodgy stuff off the internet!
• Pros and cons
• Best time to try
• Contraindications
• Orlistat policeman/dietician support.
• In conjunction with diet and exercise or dont
  have significant benefit.

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Orlistat

• Policeman
• 120mg tds
• Gallstones, medication (warfarin)
• Pros
• Cons

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Sibutramine

• 10mg and 15mg
• Contraindications
• Monitoring Requirements
• Pros
• Cons

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Rimonabant

• 20mg morning
• Central mode (canaboid receptors)
• Depression
• Monthly monitoring HAD
• Diabetics
• Triglycerides

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Bariatric Surgery

• Lap Band, Gastric bypass, Duodenal switch.
• Who? When? What? How?
• Pros
• Cons
• Follow up
• NICE guidelines/PCT. Bingo/Hoops
• Cosmetic problems

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Equipping your practice
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Case Studies and Questions